TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda Campus Brgy.

Ungot, Tarlac City

A Case Study on Obstructive Uropathy Secondary to Cystolithiasis Hydronephrosis

In Partial Fulfillment of the Requirements of the Subject Nursing Care Management 101 RLE

Presented to the Faculty Of the Tarlac State University College of Nursing Presented by: BSN III - C Group C4 Querido, Richen Raiz, Jayscent Rodriguez II, Rolando Sabat, Aprillyn Santos, Marivic Santos, Willa Milafrosa Sotelo, Jeffrey Suarez, Christine Karen Sumang, Jerico Sumaoang, Maria Luisa Date Submitted: January 09, 2010

I .Introduction

Infections of the urinary tract are a common health problem worldwide; infections include bladder infections such as cystitis, infections, stones, and Obstructive Uropathy seen almost exclusively in young women (Hooton 2000). Males are less susceptible to acute, uncomplicated infections of the bladder or the kidney, with an incidence of five to eight episodes per 10,000 men annually. As for complicated urinary tract infections, hospitalization results in almost 1 million such infections per year in the United States. Bladder catheterization is the most important cause. Developing countries exhibit a different pattern of urinary tract infection. Obstructive or reflux nephropathy is often attributed to either obstructive urophaty or urinary schistosomiasis (Barsoum 2003). Worldwide, 200 million people are affected and an estimated 300 million are at risk. Obstructive uropathy is a pathologic condition that blocks the flow of urine which predisposes those with the condition to secondary infections, stones, bladder cancers, and chronic pyelonephritis; these conditions may lead to impairment of kidney function and an increased risk of urinary infection. In the industrial countries, kidney stones are a common problem (Morton, Iliescu, and Wilson 2002), affecting 1 person in 1,000 annually, and the incidence is increasing in tropical developing countries (Robertson 2003). Factors such as age, sex, and ethnic and geographic distribution determine prevalence. The peak age of onset is in the third decade, and prevalence increases with age until 70. Although largely idiopathic, the following risk factors are associated with stone disease: low urine volume, hyperuricosuria, hyperoxaluria, hypomagnesuria, and hypocitraturia. Diarrhea, malabsorption, low protein, low calcium, increased consumption of oxalate-rich foods, and low fluid intake may play a role in the genesis of stone disease. Cystolithiasis Hydronephrosis is distention of the renal pelvis and calices by an obstruction of Normal urine flow. Urine .Urine production continues and the urine is trapped proximal to the obstruction causes of occlusion include calculus, tumor, scar tissue, congenital structural defects and a kink in the ureter.

In developing countries, 30 percent of all pediatric urolithiasis cases occur as bladder stones in children. The formation of bladder stones in children is caused by a poor diet high in cereal content and low in animal protein, calcium, and phosphates. Kidney stones can have different clinical presentations, ranging from asymptomatic to large obstructing calculi in the upper urinary tract that can severely impair renal function and lead to ESRD. Although specific causes of kidney stones should be treated appropriately, general treatment includes increased fluid intake, limited daily salt intake, moderate animal protein intake, and medical treatment with alkali and thiazides. The Afro-Asian stone-forming belt stretches from Sudan, the Arab Republic of Egypt, Saudi Arabia, the United Arab Emirates, the Islamic Republic of Iran, Pakistan, India, Myanmar, Thailand, and Indonesia to the Philippines. The disease affects all age groups from less than 1 year old to more than 70, with a male to female ratio of 2 to 1. The prevalence of calculi ranges from 4 to 20 percent (Hussain and others 1996). Urolithiasis accounts for some 50 percent of the urological workload and the bulk of urological emergencies. Patients may present with major complications leading to eventual ESRD and resulting in significant morbidity and mortality. In developed countries, only about 1 percent of patients are on dialysis because of obstructive uropathy, whereas in developing countries such as Indonesia and Thailand, obstructive uropathy is often the leading cause of ESRD, accounting for 20 percent or more of patients on dialysis. The availability of appropriately trained medical and surgical personnel and of equipment essential for treating stone disease promptly would reduce the incidence of obstructive uropathy and ESRD. Cost analyses indicate that the medical prevention of stones saves more than US$2,000 per person annually (Parks and Coe 1996).

OBJECTIVES OF THE CASE STUDY NURSE-CENTERED General: This study is aim to gain or broaden the knowledge and skills with regards to the disease condition of Obstructive Uropathy Secondary to Cystolithiasis Hydronephritis Specific: 1. To gain more knowledge about Obstructive Uropathy, Secondary to Cystolithiasis, its epidemiology, contributing factors, pathophysiology, clinical manifestations, and the treatment required 2. To enhance the student skills by performing various nursing interventions to solve or alleviate the patients needs as implementations of the formulated plans of care 3. To promote the student well being of social health by conducting a healthy social interaction with the patient 4. The nurse should be able to impart knowledge to the patient and significant others regarding the patients condition 5. To gain fulfillment during and after rendering care to the patient, thus uplifting their emotional health PATIENT-CENTERED General: To educate the client about her current condition and render nursing interventions that will respond to her needs Specific: 1. To increase the clients knowledge about her disease, which is Obstructive Uropathy Secondary to Cystrolithiasis Hydronephritis by means of giving health teachings in the contributing factors, disease course, manifestations and treatments involved

2. To address the patients needs and problems that accompany the disease by performing appropriate nursing interventions based on health care plans 3. To promote her emotional well-being by encouraging her to speak of whatever she feels about her disease condition 4. The client should be able to gain knowledge about her condition and the different ways on how to understand and accept her state of being. Reasons in choosing the Case Study Our group chose this case study to gain knowledge about the disease. The group wants to know more about the disease, its treatment, and the proper nursing management for patients with this kind of disease. The case will help the group in dealing with patient with this condition. Promotion of health, prevention of diseases and illnesses, rehabilitation and restoration of good health are important in doing the case. In the accomplishment of case study, the group will be able to know and develop more fully our skills in assessment, planning, nursing care plans, implementation/interventions and evaluation. Importance of the Study The case study is important because it would further help us in dealing with patient with the same condition and of course be competitive enough to provide the nursing management entitled for the needs of our patient. It provides broader comprehension about the condition chosen through research and actual observation as it serves as training and practice in developing learned skills in the assessment and management of the said disease. Through this case study, a holistic approach in assessing the patients health will be delivered where it can be immediately attended to and given proper interventions. It serves as a way to familiarize the students with the different medical approaches toward the ongoing curative phase. This study serves as a tool for upcoming nursing students of the school. And this is also for other nursing colleagues for them to understand the dynamics of Obstructive Uropathy Secondary to Cystolithiasis Hydronephritis as to the book-based management and actual clinical interventions. Furthermore, this study may be used as a spring board for a more advanced and in depth study that is in accordance to changing and developing society.

II. Nursing Process A. Demographic data: Name: Sex: Age: Civil Status: Birth date: Place of Birth: Chief complaint: Diagnosis: Nationality: Role in the Family: Religion: Health Care Financing: Operation : Ms. Nova Female 16-years old Single Dec. 23, 1993 Bamban Headache, abdominal pain, flank pain Obstructive Uropathy Secondary Cystolithiasis Hydronephritis Filipino Daughter Roman Catholic Philhealth RHU/Gov. Hospital Cystolithotomy

Usual Source of Medical Care:

B. Environmental Status Ms. Nova stop schooling during her 2nd year in High School. She is working as a caretaker of a little grocery store in Angeles city. As a city , their place is crowded and located near the road so smokes release by vehicles may contribute to semi-polluted air and artificial ventilation. C. Lifestyle Ms. Nova stated that as a saleslady she stands for long hours everyday and even neglect and try to tolerate when she feels that she has urge to urinate because of many costumers and ashame to ask to permission from her Boss. She also said that shes fond of salty foods, eating chichirias, adding salts to her foods and doesnt drink even the minimum amount of water. She usually sleeps at around 9:00 pm and she also ignores the feeling of being urinated at night, then wakes up at around 5:00 am,

C. History of past illness Ms. Nova according to her sister and father when she was a baby and during the age of 7(seven) at night she was lazy to stand eliminate her urine and so they just put a basin under the bamboo bed so that her urine will not spill and when she came from school she urinated her dress due to shyness that she cant asked permission from her teachers. Its already a habit for her tolerating the urge of urinating so at that at very young age of 7 she experienced already the pain of being hardly urinated with burning sensation. She has no history of serious 7

hospitalization and injuries but they just consult and keep on going back to the Doctor whenever she felt the pain of hardly urinating or had fever. She drunk the prescribed drugs just to relieve. But her habits that contribute to her chief complaint also continue. She mentioned that she had chicken pox and some minor injuries during her school-age years. She has no known allergies to food, medications, animals, dust, etc. Patient sister also said that Ms. Novas immunization was not completed and had her BCG immunizations when she was in Grade I. She usually feels headache and dizziness. Some medications she took are antibiotic, paracetamol, and other OTC medicines for cough, colds and headache. D. History of Present illness Ms. Nova cant tolerate the pain she felt so her family decided to bring her to the hospital. Two weeks prior to hospital admission Ms. Nova at work experienced difficulty urinating and cant tolerate of even standing because of painful sensation and has blood tinged when urinating. She decided to go home, stay their for another one week just lying on the bed and try to self medicate with the former drugs prescribed, drink water and boiled pancit pancitan leaves but these cant alleviate the fever ,pain, then no increase of urine output and her small amount of her urine is almost bright orange with blood tinged and cant tolerate stand. According to her its a Right abdominal pain radiating to flank pain. So her sister and parents decided to bring her to the hospital because of suffering too long in their home. She was rushed to Tarlac Provincial Hospital and observe for 1 week more. She was given IV Fluid and undergone laboratory exams like urinalysis , CBC, abdominal X Rays, Whole Abdomen Ultrasound , Urine culture and sensitivity and even Chest X Ray and Pregnancy Test( outome as Negative).And finally the abdominal X-Ray, Urinalysis, Urine Serum Creatinine .CBC, and the Whole Abdomen Ultrasound rebel that there was a large radiopaque density in the pelvis consider urinary bladder calculus. And Diagnose by the doctor as Obstructive Uropathy Secondary to Cystolitiasis Hydronephritis . So after these series of diagnostic tests for more than

one and a half week in the hospital Cystolithotomy.

she was undergone an operation called

13 Areas of Assessment A.Social Status

December 05, 2009

Ms Nova is a 16 years old single and works as a caretaker of a grocery store. She just visit and stay with her family during her vacation .During her vacation she visits her brothers and sisters with families and giving what she brings home as pasalubong, visit her friends and at home watching T.V.,helping in household chores, talking with neighbors. She lives together with her father and mother and single brother and sister. The family maintains a good relationship with each other. According to her they express their concern within the family by helping each other when they have their problem. NORMS: The ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinion and beliefs. (Kozier B. 2004, Fundamentals of Nursing Concepts, Process and Practice Seventh Edition p.172) Families consist of persons and their responsibilities within the family. A family structure of parents and their offspring is known as the nuclear family (Kozier B. 2004, Fundamentals of Nursing Concepts, Process and Practice Seventh Edition p.191) The ability to achieve balance between work and leisure time. A persons belief about education, employment and home influence personal satisfaction and relationships with others (Kozier B. 2004, Fundamentals of Nursing Concepts, Process and Practice Seventh Edition p.173)

INTERPRETATION: The clients social status is in a well state as manifested by the client, having no problems in interacting with other persons especially in her family. She fulfills her part in the family and able to manage her time (doing the house hold chores, watching television, etc.) B.Mental status/Neurological Status During the assessment, the patient is oriented to time, date and place. By answering our question Kailan ka pa rito at kalian ka naoperahan? She response November 17 pa ako nandito, halos sobra dalawang Linggo na ako at kahapon lang ako naoperahan December 04.She gave accurate information and appropriate answers to the questions being asked. The patient exhibits right answer but demonstrating poor eye to eye contact because shes still in pain. NORMS: Consciousness: Being aware of ones own existence, feelings and thoughts and aware of the environment. Language: Using the voice to communicate ones thoughts and feelings. Attention: The power of concentration, the ability to focus on one specific thing without being distracted. Memory: The ability to lay down information and store experience. (Carolyn Jarvis, Physical Examination & Health Assessment 3rd Edition) INTERPRETATION: The patient is not demonstrating any signs of alteration in her mental status. She has normal cognition during the interview and able to answer accurately to the questions being asked to her. C.Emotional Status During interview, Ms. Nova shown poor eye contact with facial tension and restless. On the other hand during the interview Ms. Nova expressed frustrations because she never thought that all the things that she have done were all wrong that leads her in having her condition. She admitted that shes fond of eating salty foods, chichiria and drinking softdrinks, tolerating urine at night and during working time and drinking just small amount of water NORMS:

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A person expresses themselves as optimistic and a positive thinker in life. There should no presence of fear, anxiety, grieving etc. The patient should have the ability to manage stress and to express emotions appropriately. It also involves the ability to recognize, accept, and express feelings and to accept ones imitations. (Kozier, B. (2004). Fundamentals of Nursing: Concepts, Processes and Practice. Seventh edition) INTERPRETATION: The client is able to express her fear and anxiety in life due to her condtion. D.Sensory Perception Sense of Sight Based on the assessment, Ms. Nova has no alteration in sense of sight.. Her eyes are symmetrical and round and sclera is white in color. NORMS Eyes symmetrically aligned, equal movement, eye bilaterally blinking, sclera appears white, skinny smooth conjunctiva no edema and tenderness on lacrimal gland. Eyes glasses are use to correct refractive disorders. Sense of Taste Ms. Nova does not have any alteration in her taste, she can able to determine the foods taste as she mentioned that she can differentiate various taste such as sour, bitter, sweet and others with the foods that she eats. Her tongue is reddish and in normal position and can move freely. NORMS: Tongue is reddish/pink in color, central in position, no lesions, raised papillae (taste buds), moves freely, no tenderness no palpable nodules. Tactile Sensitivity Upon examination, one of the group member pinched her right and left arm and ask her to tell the sensation. The patient responded and verbalized what she felt and stated that she felt pain when she was pinched. She complains with post-operation pain with the pain scale of 7/10 during the interview. NORMS: The skin contains receptors for pain, touch, pressure and temperature. Sensory signals that help determine precise locations on the skin are transmitted along rapid sensory pathways, and

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less distinct signals such as pressure or poorly localized touch are sent via slower or sensory pathways. (Health Assessment and Physical Examination, Mary Ellen Zator Estes 5th Edition) INTERPRETATION: The patients sensory transmission functions are within the normal as manifested by the data presented. E.Motor Stability Ms. Nova is still at bed rest and move on bed with assistance . She feels pain,easy fatigability and weakness during minimal movements.

NORMS: Normal muscle strength allows for complete voluntary range of joint motion against both gravity and moderate to full resistance. Muscle strength is equal bilaterally. A healthy person can perform the different Range of Motion (ROM). (Health Assessment and Physical Examination, Mary Ellen Zator Estes 5th Edition) INTERPRETATION: She has slight alteration in his motor stability because of pain,easy fatigability and weakness. F.Body Temperature Date and Time December 04, 2009; 03:52 pm November 05, 2009; 04:30 pm December 06, 2009; 03:45 pm NORMS: The normal body temperature ranges from 36.5 to 37.5oC (Fundamentals of nursing Kozier 2004, 7th edition) INTERPRETATION: Based on the given norms the patients body temperature has alteration due to infection caused by her present condition Results 38.3 0C via axilla 38.0 0C via axilla 37.80C via axilla

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G. Respiratory Status Date and Time December 04 , 2009; 03:52 pm December 05, 2009; 05:30 pm December 06, 2009; 05:45 pm Results 19 cpm No retraction 17 cpm No retraction 16 cpm No retraction

NORMS: There should be an absence of retractions and bulging of the (Inter Coastal Spaces) ICS. In the resting adult, the normal respiratory rate is 12 to 20 breaths per minute. INTERPRETATION: Upon assessment Mrs. Clover showed normal respiratory status. H.Circulatory Status On assessment the patient exhibit good capillary refill after the Blanch Test by applying gentle pressure at the nail beds it return at 2 seconds. She had a blood pressure reading of 100/80 mmHg and pulse rate of 84bpm. ( December 05, 2009; 03:52 pm) Date and Time December 04, 2009; 03:52 pm December 05, 2009; 05:30 pm December 06, 2009; 05:45 pm Result 100/80mmHg 90/80mmHg 100/80mmHg

Pulse rate Date and Time December 04, 2009; 03:52 pm December 05, 2009; 05:30 pm December 06, 2009; 05:45 pm Result 84bpm 89bpm 95bpm

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NORMS: Blanch test should return at 1 to 2 seconds and Normal blood pressure is 120/80 mmHg and the pulse rate is 60-100 bpm in adults. (Kozier, 2006) INTERPRETATION: Based on the data shown Ms. Nova blanch test is normal but her bp is slightly below Normal because of her present condition

I.Nutritional Status During our assessment Ms. Nova is thin in appearance and her height is 4 feet and 5 inches. Her nutritional status she suffering from nutritional imbalance she eats 2-3 times a day. She usually takes small amount of water like a glass of water daily is enough. She usually eats vegetables and salty foods like junk foods and plenty of softdrinks, then tolerating urge to urinate. Computation Formula of BMI BMI=WEIGHT IN KG/ HEIGHT IN M NORMS: Normal eating pattern is on the minimum of 3 5 times per day, depending upon metabolic need and demands. Fluid is on the average of 8-10 glasses (2-3 liters) per day. Body Mass Index Interpretation (Javis, 2000) <18.5 ------------------------------ underweight 18.5 24.9 ----------------------- healthy 25.0 29.9 ----------------------- overweight 30> -------------------------------- obese EQUATION BMI= 25kg ________________ RESULT UNDERWEIGHT

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Food pyramid (SOURCE: Physical Assessment and Health Examination 4th Edition, Carolyn Jarvis) INTERPRETATION: Her BMI was interpreted as underweight (________ ). There is a problem in her eating habits and her fluid intake was in below normal. J.Elimination Status Upon assessment, the urine output of Ms. Nova was in 38 ml around 2 hours. Slightly red in appearance and with pain during urination. Usually had a bowel movement of 1-2 times per day. Patient experienced frequent urination but in small amount. NORMS: Normal bowel movement is 1-3 times per day and voids at 1,200 1,500 mL per day or 3060 ml the normal color of stool is brown and well formed the urine is clear and yellowish in color(health assessment and physical examination,3rd edition by Mary Ellen zastor estes). INTERPRETATION: The client experience hematuria due to her condition. This is because of the inflammation of her kidney. K.Rest and Sleep

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Ms. Nova stated that she only sleeps at 9:00 PM and wakes up at 5:00 AM. She usually sleeps 6-7 hours at night but has a disturbed sleeping pattern due to her painful urination with blood tinged. NORMS: Normal sleeping pattern of children about 8-10 hours of sleep at night (Kozier, 2004) INTERPRETATION: The patient sleeps inadequately due to her disturbed sleeping patterns. She is not able to complete the normal sleep hours.

L.Reproductive Status Ms. Nova had her first menarche when she was 14 years old her cycle usually last for 7days she experiences headache and pain on the pelvic area during her cycle she usually use 4 pads with fully soak blood Standard: Menarche which is the first menstruation occur at an average age of onset between 9 to 17 years old (maternal and child health nursing 4th edition by pilliterri) INTERPRETATION: The patient had a normal reproductive system since she had her menarche at the right age M.State of Skin Appendages Generalized color; Ms. Nova had fair complexion Texture; There is no redness noted but experienced itching when IVP drugs administered Moisture; the skin is dry perspiration was absent to her Temperature; the patient skin was warm and dry. NORMS: Normally, the skin is a uniform whitish pink or brown color, depending on the patients race. There are no areas of increased vascularity, ecchymosis, or bleeding. No skin lesions should be present except for freckles, birth marks or moles, which may be flat or elevated. The skin is dry 16

with a slight perspiration present on the hands, axilla, face and in between the skin folds. Skin should normally feel smooth, even and firm except when there is significant hair growth. A certain amount of roughness can be normal, hair varies from dark black to pale blonde based on the amount of melanin present in light-skinned individuals and light brown in dark-skinned individuals. The nail surface should be smooth and slightly rounded and flat. INTERPRETATION: Ms. Nova skin and appendages status was not affected there is no presence of redness on her skin and its warm to touch.

6. Diagnostic & Laboratory Procedures

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Diagnosis & laboratory procedures 1.Urinalysis

Purpose

Normal Values (book based) Color : straw amber, transparent Appearance: clear Specific gravity: 1.010-1.022 protein : negative bacteria : negative

Actual Results Color Orange Appearanc e: Hazy Specific gravity: 1.028 protein : negative bacteria : Many

Interpretation

To determine urine composition & possible abnormal components or infection.

Urine Concentrated Cloudy /puss Urine Concentrated

Negative Presence of bacteria/blockag e causing urine concentrated. Presence of blockage causing irritation to bladder Presence of blood in the urine.

Puss Cells None

pus cells : Loaded

2.24hour Urine

RBC Female:02/hpf Amorphous urates 4.42-5.9 mmol/d

10-20 Moderate

Nursing Responsibility: Before: collect the specimen for the client and assist the client when assistance is needed. During: Specimen must be free from any contamination. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

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Diagnosis & laboratory procedures 3.Catheter ization

Purpose

Normal Values (book based) Normal flow of urine pass

Actual Results

Interpretation

For Urine elimination

Catheter is difficult to pass

A urethral obstruction (eg, prostatic enlargement, stricture, or valve) is suspected.

Nursing Responsibility: Before: Catheter must be free from any contamination. During: Use lubricant. Check if tubing difficult to pass. After: Do not force if not catheter tubing not passable.

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Diagnosis & laboratory procedures 4.Pregnanc y Test

Purpose

Normal Values (book based) (-) Negative if the 1st box has shade. (+)Positive if 2nd & 3rd box has shade.

Actual Results

Interpretation

To determine through urine of a woman if Pregnant

Negative

(-) 1st box has Shade. Not Pregnant

Nursing Responsibility: Before: Instruct the client on how to collect the specimen and assist the client when assistance is needed. If not pregnant advise client to drink 8 glasses of water (full bladder). During: Instruct client to collect the middle urine. Specimen must be free from any contamination. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

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Diagnosis & laboratory procedures 5.Hematology

Purpose

RBC, Hgb, WBC Increase WBC Presence of Hct, is 3.0 infection important to Decrease RBC due to the oxygen RBC- 3.6RBC inadequate nutrients intake carrying 8.0 x 10 /L 5.53 capacity of Decrease RBC due to the blood. Hgb- 120Hgb inadequate nutrients intake WBC is an 170 g/L 102 g/L indicator of immune Hematocrit- Hematocrit- Presence of infection infection. 0.37-0.48 % 0.323% Creatinine Creatinine To detect obstruction. Nov.11,2009 341.87 Infection with urinary obstruction requires immediate evaluation and treatment. Nov.19,2009 Nov21,2009 Nov.24,2009 Nov.29,2009 327.09 248.18 212.16 132.6 TypeB -do-do-do-do-

Normal Values (book based) WBC- 4.510.0 x 0 9/L

Result

Interpretation

6.Blood Type

For Cross Matching

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Nursing responsibilies: Before: Inform the client that he/she will going to undergone CBC and blood typing. During: Assist the client while getting blood. Assist the venipuncture site for bleeding after. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

Diagnosis & laboratory procedures 7. Chest XRay

Purpose

To visualize Lungs and Heart.

Normal Values (book based) Lungs are intact and clear. No enlargement of the heart noted. Normal

Result

Interpretation

Normal

Normal

8.Abdominal To visualize X-Ray abdomen

A large radiopaque density is seen in the pelvis 22

Consider a large urinary bladder calculus.

Nursing responsibility: For Chest X-Ray: 1. Determine the patients ability to hold his breath. 2. Ensures that the patient removes all jewelries before the X-Ray taken. For abdominal X-Ray: During: 1. Assist the patient to lie still . After: Assist pt. to stand.

Diagnosis & laboratory procedures 9.ULTRASOU ND (Whole Abdomen Ultrasound)

Purpose

To visualize the abdomen if pregnant, has mass noted to det. its size,shape,color,co nsistency.

Normal Result Values (book based) No fetus noted Bilaterally or no mass hydronephrosis noted. Secondary to bilateral Ureteral Obstruction at the level of Ureterovesical junction. Bilateral renal parenchymal disesases. Urinary bladder wall cystitis. Normal liver,visualized pancreas, spleen.\ Partially distended gallbladder otherwise unremarkable.

Nursing responsibilities:

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Before: .If not pregnant let pt. drink 8 glasses of water (full bladder) During: Ensure the ability of the patient to lie still. Apply lubricant to the abdomen After: .Wipe the lubricant with tissue. .

Anatomy and Physiology

EXTERNAL ANATOMY KIDNEY

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They are paired that are reddish in color and resemble beans in shape. They are about size of a close fist located at retro peritoneally ( behind and outside peritoneal cavity) on the posterior wall of the abdomen from 12 thoracic vertebrae to the third lumbar vertebrae in adult. The average adult kidney weighs approximately 133-170g. (4.5 oz) and is 10-12 cm long 6 cm wide and 2.5 cm thick the right kidney is slight lower than the left due to the location of the liver. Kidney are well protected by the ribs and by the muscles of the abdomen and back3 LAYERS OF TISSUE SURROUNDING EACH KIDNEY 1..RENAL CAPSULE- innermost layer, it is a smooth transparent fibrous connective tissue membrane that connects with the outermost covering of the ureter at the hilum. It serves as a barrier against infection and trauma to the kidney 2.ADIPOSE CAPSULE-second layer it is a mass of fatty tissue that protects the kidney from blows. It firmly holds the kidney in the abdominal activity 3.RENAL CAPSULE- outer most layer which consist of a thin of a layer of fibrous connective tissue that also anchors the kidney to their surrounding structures and to the abdominal wall INTERNAL ANATOMY OF KIDNEY The renal parenchyma is divided into two parts the cortex and the medulla Medulla is approximately 5 cm wide which is the inner portion of the kidney. It contains the loop of Henle, the Vasa Recta and the collecting ducts of the juxtamedullary nephrons the collecting duct from both the juxtamedullary and the cortical nephrons connect to renal pyramids which are triangular and are situated with base facins the concave surface of the kidney and the point (papilla)facins the hilum/pelvis. Each kidney contains approximately 8-18 pyramids. The pyramids drain into 4 to 13 minor calices which drain into 2 major calices that open directly into the renal pelvis. The renal pelvis is the beginning of the collecting system and is composed of structures that are designed to collect and transport urine. Once the urine leaves The renal pelvis, the composition of urine does not change. CORTEX- It is approximately 2 cm wide, is located farthest from the center of the kidney and around the outer most edges. It contains the nephrons. NEPHRONS-these are the functional units of kidney. It is microscopic renal tubule which functions as a filter. Each kidney has 1 million nephrons, which usually allows for adequate renal

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function even if the opposite kidney is damaged or becomes nonfunctional. The structures are located within the renal parenchymas that are responsible for initial formation of urine. 2 KINDS OF NEPHRONS a. Cortical nephrons this makes up 80 to 85 % of total number of nephrons in the kidney which are located in the innermost part of the cortex. b. Juxtamendullary nephrons which make up the remaining 15 to 20 % are located deeper in the cortex. There are distinguished by long loops of Henle, which are surrounded by long capillary loops called Vasa Recta that dip into Medulla of the Kidney. Nephrons are made up of two basic components; a filtering element component of an enclosed capillary network and the attach tubule. The glumerulus is a unique network of capillaries suspended between the afferent and efferent blood vessels, which are enclosed in an epithelial structure called Bowmans capsule. The glumerular membrane is composed of three filtering layers: (a) Capillary endothelium, (b) basement membrane, and (c) epithelium. This membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as blood cells and albumin. The tubular component of the nephrons begins in the Bowmans capsule. The filtrate created in the Bowmans capsule travel first into the proximal tubule, then into loops of Henle, distal tubule, and either the cortical or medullary collecting ducts. The structural arrangement of the tubule allows the distal tubule to lie in close proximity to where the afferent and efferent arteriole respectively enter and leave the glumerulus. The distal tubular cells located in this area, known as the Macula Densa which functions with the adjacent afferent arteriole and create what is known as juxtaglumerulus apparatus. This is the site of the renin production. Renin is a hormone directly involved in the control of arterial blood pressure; it is essential for proper functioning of the glumerulus. The tubular component consists of the Bowmans capsule, the proximal tubule, the descending and ascending limbs of the loop of Henle, and the cortical and medullary collecting ducts. This portion of the nephrons is responsible in making adjustments in the filtrate based on the bodys needs. Changes are continually made as the filtrate travels through the tubules until it enters the collecting system and is expended from the body.BLOOD SUPPLY TO THE KIDNEYThe hilum of pelvis is the concave portion of the kidney through which are renal artery enters and ureters and renal vein exit. The kidney received 20% to 25% of the total cardiac output, which means that all of the bodys blood circulates through the kidneys approximately 12 times per hour. The renal artery (arising from the

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abdominal aorta) divided into smaller and smaller vessels, eventually forming the afferent arterioles. Each afferent arterioles branch to form a glumerulus, which is the capillary bed responsible for glumerular filtration.

OBSTRUCTIVE UROPATHY Secondary to TO CYSTOLITIASIS HYDRONEPHROSIS Obstructive Uropathy(Urinary Tract Obstruction)is structural or functional hindrance of normal urine flow, sometimes leading to renal dysfunction (obstructive nephropathy). Symptoms, less likely in chronic obstruction, are pain radiating to the T11 to T12 dermatomes, anuria, nocturia, or polyuria. Diagnosis is based on results of bladder catheterization, ultrasonography, CT, cystourethroscopy, cystourethrography, or pyelography, depending on the level of obstruction. Treatment, depending on cause, may require prompt drainage, instrumentation, surgery (eg, endoscopy, lithotripsy), hormonal therapy, or a combination of these modalities. Each year about 2/1000 people in the US are hospitalized for obstructive uropathy. The condition has a bimodal distribution. In childhood, it is due mainly to congenital anomalies of the urinary tract. Incidence then declines until after age 60, when incidence rises, particularly in men

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because of the increased incidence of benign prostatic hyperplasia (BPH) and prostate cancer. Overall, obstructive uropathy is responsible for about 4% of end-stage renal disease. Cystolithiasis Hydronephrosis is distention of the renal pelvis and calices by an obstruction of Normal urine flow. Urine .Urine production continues and the urine is trapped proximal to the obstruction causes of occlusion include calculus, tumor, scar tissue, congenital structural defects and a kink in the ureter. Whatever the cause, the accumulating urine exerts pressure on the renal pelvis wall. At low to moderate exerts pressure on the renal pelvis wall. At low to moderate pressures the kidney may dilate with no obvious loss of function. Overtime, sustained or intermittent high pressure causes irreversible nephron destruction. In addition to pressure-related problems, pyelonephritis is always a risk because of urinary stasis. Treatment aims to relieve the obstruction and prevent infection. Depending on the location of the obstruction, it may involve placement of a ureteral catheter or stent above the point of obstruction. Typically, surgery is required to relieve the obstruction and restore adequate of the urinary system. Removal of the obstruction results in sudden release of the pressure on the renal parenchyma caused by the trapped urine, which leads to dieresis. Thus post obstructive diuresis occurs and can lead to fluid and electrolyte imbalances including dehydration. The kidney gradually begins to concentrate urine approximately. Hydronephrosis found at postmortem examination in 2 to 4% of patients if not detected earier. . Many conditions can cause obstructive uropathy, which may be acute or chronic, partial or complete, and unilateral or bilateral . In children, the most common causes are anatomic abnormalities (including urethral valves or stricture and stenosis at the ureterovesical or ureteropelvic junction). In young adults, the most common cause is a calculus. In older adults, the most common causes are BPH or prostate cancer, retroperitoneal or pelvic tumors, and calculi. Obstruction may occur at any level, from the renal tubules (casts, crystals) to the external urethral meatus. Proximal to the obstruction, effects may include increased intraluminal pressure, urinary stasis, UTI, or calculus formation (which may also cause obstruction). Obstruction is much more common in males, but acquired and congenital urethral strictures and meatal stenosis occur in both males and females. In females, urethral obstruction may occur secondary to a tumor or as a result of stricture formation after radiation therapy, surgery, or urologic instrumentation (usually repeated dilation).

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In an asymptomatic patient with long-standing obstructive uropathy, urinalysis may be normal or reveal only a few casts, WBCs, or RBCs. In a patient with acute renal failure who has a normal urinalysis, bilateral obstructive nephropathy should be considered.

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PATHOPHYSIOLOGY OBSTRUCTIVE UROPATHY 2 to CYSTOLITHIASIS HYDRONEPHROSIS (Book Based) PATHOPHYSIOLOGY

Non-Modifiable Factors Age: Children: Anatomic abnormalities (including urethral valves or stricture and stenosis at the ureterovesical or ureteropelvic junction). In young adults: the most common cause is a calculus. In older adults: the most common causes are BPH or prostate cancer, retroperitoneal or pelvic tumors, and Calculi Sex: Males=obstruction more common Females=urethral obstruction occur 2 to tumor,calculus or as result of stricture formation ( Occur in both F. & M.= acquired and congenital urethral strictures and meatal stenosis

Modifiable Factors Lifestyle: *High Salt Diet * Drinking small amount of water *Tolerating urge to urinate *Dehydration *UTI

A low and high Calcium intake

Supersaturation of urine w/solutes.

Matrix formation caused when muco preoteins bind to the mass of stone

Lack of inhibitors e.g. (citrate,pyrophos phate & magnesium as chelating agent)caused by or absent protectors against

Combination of these conditions

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Pain is common when obstruction acutely distends the bladder, collecting system (ie, the Anuria ureter plus the renal calyces), or renal capsule.

Nausea

Vomiting

Anuria

Difficulty voiding or abnormalities of the urine stream.

if

Complete Obs. or Absolute Anuria if in Urethra or bladder level

Partial obstruct ion

Bilateral Ostruction, nephropathy may result in renal insufficiency

If Upper ureteral or renal pelvic lesions causes flank pain or tenderness

If Lower ureteral obstruction pain that may radiate to the ipsilateral testicle or labia.

suggestive is a pattern of oliguria or anuria alternating withPolyuria & Nocturia Rarely urine output is often normal =if the ensuing Nephropathy

If Impaired Renal concentratin g capacity & Na reabsorption

.
Crystallization= form & growth continues into larger particles & may travel down the urinary tract & if present in larger amounts .

Cystolithiasis Hydronephritis

Act to keep crystals forming stones account for Family Hx. of Urolithiasis. (OBSTRUCTIVE UROPTHY )

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PATHOPHYSIOLOGY OBSTRUCTIVE UROPATHY 2 to CYSTOLITIASIS HYDRONEPHROSIS (PatientBased)

Non-Modifiable Factors Age: Young adults: the most common cause is a calculus. Females=urethral obstruction occur 2 to tumor,calculus or as result of stricture formation ( Occur in both F. & M.= acquired and congenital urethral strictures and meatal stenosis Modifiable Factors Lifestyle: *High Salt Diet(chichiria Adding salt to foods, * Drinking small amount of water *Tolerating urge to urinate *Dehydration *UTI

Flank Pain

Headache Headache

Vomiting

Fever

Abdominal pain

Anuria

Crystallization= form & growth continues into larger particles & may travel down the urinary tract & if present in larger amounts.

Difficul ty voiding

If Impaired Renal concentratin g capacity & Na reabsorption

Bilateral Ostruction, nephropathy may result in renal insufficiency

(OBSTRUCTIVE UROPTHY ) Secondary to

Cystolithiasis Hydronephritis

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C. Implementation 1. Medical Management A. Intravenous Fluid Name of drugs (generic & brand name) 1.PNSS Route of administration, dosage & frequency of administration IV Fluid / Left or Right arm vein 1L,20gtts/min General mechanism of action Infusion of Isotonic solution with Na, fl,K, Ca. & Lactate. concentration same as plasma -doIndication & Purposes This IV solution that contain balance concentration with plasma -doClient response to medication with actual response Maintain hydration & regain energy.

2.Plain LRS With Vit. B complex

IV Fluid / Left or Right arm vein 1L, 20gtts/ min

-do-

Nursing Responsibilities: Before administration: Monitor vital signs. Assist in administering medication. During the administration: Regulate the IV fluid according to regulation order. After the medication: 38

Monitor for fluid overload.

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B. Medication Route of Name of administrati General drugs on, dosage action of (generic & & frequency mechanism brand name) of administrati on 1.Paracetamo 300 mg, It reduce (Acetaminop IVP q 4 fever by hen) hours direct action on the hypothalamus heat regulating system leading to vasodilation and sweating it also possibly by inhibiting the action of endogenous pyrogen. Nursing Responsibilities: Before administration: Monitor vital signs. Assist in administering medication. During the administration: Measure and record the vital signs, especially the temperature. After the medication: Monitor the clients body temperature. Be alert to adverse reactions and drug interaction. Indication & Purposes Client response to medication with actual seen

Treatment for fever and for relief of mild to moderate pain associated with bacterial and viral infection

Patient reports fever reduce with drug.

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Name of drugs (generic & brand name) 2.Dexamet hasone

Route of administrat General action ion, dosage of mechanism & frequency of administrat ion 40 mg. IVP *May stabilize PRN leukocyte lysosomal membranes; stimulate bone marrow; and influence protein ,fat and carbohydrate metabolism

Indication & Purposes

Client response to medication with actual side effect

*An antiinflammatory *Immunosuppresant *Relieves cerebral edema, reduces inflammation and immune response and reverse shock.

Patients improve with drug therapy.

Nursing Responsibilities: Before administration: Monitor vital signs. Perform skin testing. Assist in administering medication. During the administration: Monitor vital signs. After the medication: Be alert to adverse reactions and drug interaction. Name of drugs (generic & brand name) Route of administr General action ation, of mechanism dosage & frequency of administr ation gm. IVP * Inhibits cell wall synthesis, promoting osmotic 41 Indication & Purposes Client response to medication with actual side effect

3.Ceptriaxone

*Antibiotic *Hinders or kills

Patient is free from infection and maintain hydration.

instability;usuall y bactericidal.

susceptible bacteria

NURSING RESPONSIBILITIES: (Before) a) Explain the importance and action of drugs to the client of significant others. b) Obtain culture and sensitivity test c) Tell possible reaction or side effect of the drugs. ( During) a) If G.I. reaction occur, monitor hydration Route of administrati General on, dosage action of & frequency mechanism of administrati on IVP *May inhibit prostaglandi n synthesis .

Name of drugs (generic & brand name) 4.Ketorolac

Indication & Purposes

Client response to medication with actual side effect

*Analgesic *antiinflammatory *Relieves pain and inflammation

Patient is free from pain.

Nursing Responsibilities: (Before) Assess pts pain. (After) Advise pt. to report sign and symptoms of G.I. bleeding Explain that the drug is intended for short term use.

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Name of drugs (generic & brand name) 5.Omepraz ole

Route of administrati General action of on, dosage mechanism & frequency of administrati on 40mg. IVP Inhibits q 12 hours x acid(proton) pump 2 and binds to hydrogenpotassium adenosine triphosphatase on secretory surface of gastric parietal cells to block formation of gastric acid.

Indication & Purposes

Client response to medication with actual side effect Patients responds well to therapy and maintain hydration..

*For heartburn *Relieves symptoms caused by excessive gastric acid.

Before administration: Monitor vital sign During the administration: After the medication: Be alert to adverse reactions and drug interaction

Route of Name of administrati General action of drugs on, dosage mechanism (generic & & frequency brand of name) administrati on 6.Tramadol 50mg.IVP q Unknown centrally acting 4 hours synthetic analgesic PRN compound not chemically related to opiods that is thought to bind to opiod receptors and inhibits the reuptake of noeripenephrine and serotonin. Before administration: Monitor vital sign

Indicatio n& Purposes

Client response to medication with actual side effect Patient is free from pain and regains normal bowel elimination.

*Relieve s pain.

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During the administration: Closely monitor pt. at risk for seizures. Withhold drug if R.R. decrease to 12 bpm. Constipation is common adverse effect, anticipate need for laxative. After the medication: Be alert to adverse reactions and drug interaction C. Diet Type of diet Diet as tolerated with limited Salt and Fat intake General Description Eating any kind of food but limit and intake of fat and salt. Indication & Purposes It not contraindicated to Postoperated pt. Specific foods taken Vegetables, fruits rich in vitamin C, fiber rich foods, whole grains, eggs, cheese, meat, poultry and tomatoes. Client response and or reaction to the diet The clients condition regain and increased energy.

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CONCLUSION Having series of research about Obstructive Uropathy Secondary to Cystolithiasis Hydronephritis, its management and after completing the case study, the group had come out with the following conclusion: Patients condition was enough proven by adequate data gathered. Proper analysis was made so that nursing problems were formulated. Evaluated patients health situation through Hospital Duty by health teaching like nursing interventions about diet and drugs.

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RECOMMENDATION Having studied the condition of the patient, we come up with the following recommendation: Medication: Continue medications as prescribed Prescribed medication must be taken on time Exercise: Strenuous exercise should be avoided Encouraged to take enough rest to regain strength Treatment: Take home medications as doctors order Report unusual signs and symptoms Health Teachings: Advised the client to have enough bed rest Upon discharge patient education should emphasize the importance of close follow up care Encourage to practice personal hygiene properly Void when there are urged to urinate Wipe from back to front to prevent bacteria around the anus from entering the vagina or urethra Diet: Diet as tolerated(DAT) with limited Salt and Fat Intake as ordered Increase fluid intake Advised the patient to eat vegetables, fruits rich in vitamin C and fiber rich foods.

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